Who We Are

Point32Health is a leading health and wellbeing organization, delivering an ever-better personalized health care experience to everyone in our communities. At Point32Health, we are building on the quality, nonprofit heritage of our founding organizations, Tufts Health Plan and Harvard Pilgrim Health Care, where we leverage our experience and expertise to help people find their version of healthier living through a broad range of health plans and tools that make navigating health and wellbeing easier.

We enjoy the important work we do every day in service to our members, partners, colleagues and communities. To learn more about who we are at Point32Health, click here.

Job Summary

Key Responsibilities/Duties – what you will be doing

Role Overview: Lead the execution of a strategic plan to ensure compliance with federal and state laws and regulations related to the Government Programs Compliance Programs for Medicare and Duals products. This role involves guiding teams and processes while fostering a culture of integrity.

Key Responsibilities:

• Leadership & Strategy: Develop and implement effective compliance strategies, ensuring adherence to Federal Medicare and State requires related to Medicare Advantage and Prescription Drug Plans and Dual Programs (SCO and One-Care).
• Regulatory Compliance: Manage and maintain a robust regulatory compliance infrastructure that aligns with corporate governance programs.
• Stakeholder Relations: Maintain strong relationships with CMS/EOHHS regulators, serving as the primary liaison to address concerns and advance business and regulatory priorities.
• Policy Development: Create and enforce policies, procedures, and practices to ensure compliance with healthcare program requirements.
• Collaboration: At the direction of the Medicare Compliance Officer, collaborate with leadership and department heads to promote compliance awareness and foster positive relationships between compliance and operations teams.
• Information Dissemination: Ensure that leadership and employees are well-informed about regulatory issues and requirements.
• Administrative Management: Oversee the compliance unit’s administrative tasks, including document organization, report preparation, and staff supervision.
• Performance Monitoring: Track compliance performance across operational areas.
• Investigations & Reporting: Conduct compliance investigations, prepare reports, and monitor remediation efforts.
• Risk Assessment: Support the implementation and maintenance of a coordinated risk assessment process.
• Vendor Oversight: Support the development and maintenance of oversight programs for vendors (FDRs and Material Subcontractors).
• Audit & Monitoring: Support Audit and Monitoring unit to develop and implement compliance work plans.
• Corrective Actions: Monitor and report on the effectiveness of corrective action plans.
• Fraud Prevention: Work with the Fraud Special Investigations Unit to ensure compliance with CMS requirements.
• Reporting: Provide updates and reporting to the Government Programs Compliance Officer to support the Compliance Committee and other meetings as needed.
• Monitoring & Reviews: Support the coordination of both external and internal compliance reviews.

This role requires a proactive leader who can work autonomously, communicate effectively, and build strong relationships to ensure the success of the compliance program.

Qualifications – what you need to perform the job

EDUCATION: Bachelors Degree

EXPERIENCE:

Minimum of 5-7 years of directly related experience (5+ years of Medicare and/or Medicaid Compliance experience) in personnel management and compliance related activities, legislative and regulatory activities, health insurance operations or legal research or equivalent combination of education and experience.

Strong experience with Medicare and/or Medicaid health care products is required. Demonstrated knowledge of government regulations as they relate to the administration of Medicare and/or Medicaid healthcare programs, principles and practices of managed care. Project coordination and management experience.

SKILL REQUIREMENTS:

• Ability to influence others at all levels across the organization without direct reporting authority
• Strong research, writing, public speaking and computer skills
• Understanding of health policy issues related to medical and other healthcare activities.
• Strong subject matter expertise in Medicare and/or Medicaid Operations and Compliance Requirements
• Demonstrated effectiveness operating in complex organizational environments.
• Excellent written, oral, and presentation communication skills.
• Proven ability to work with all levels of management.
• Strong problem-solving skills.
• Demonstrated ability to partner effectively with others in the handling complex issues
• Strong leadership skills with ability to lead cross functional teams
• Ability to develop and support staff in their professional development
• Sense of Humor

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Compensation & Total Rewards Overview

As part of our comprehensive total rewards program, colleagues are also eligible for variable pay. Eligibility for any bonus, commission, benefits, or any other form of compensation and benefits remains in the Company's sole discretion and may be modified at the Company’s sole discretion, consistent with the law.

Point32Health offers their Colleagues a competitive and comprehensive total rewards package which currently includes:

• Medical, dental and vision coverage

• Retirement plans

• Paid time off

• Employer-paid life and disability insurance with additional buy-up coverage options

• Tuition program

• Well-being benefits

• Full suite of benefits to support career development, individual & family health, and financial health

For more details on our total rewards programs, visit https://www.point32health.org/careers/benefits/

Commitment to Diversity, Equity, Inclusion, Accessibility (DEIA) and Health Equity

​Point32Health is committed to making diversity, equity, inclusion, accessibility and health equity part of everything we do—from product design to the workforce driving that innovation. Our Diversity, Equity, Inclusion, Accessibility (DEIA) and Health Equity team's strategy is deeply connected to our core values and will evolve as the changing nature of work shifts. Programming, events, and an inclusion infrastructure play a role in how we spread cultural awareness, train people leaders on engaging with their teams and provide parameters on how to recruit and retain talented and dynamic talent. We welcome all applicants and qualified individuals, who will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status.

Scam Alert: Point32Health has recently become aware of job posting scams where unauthorized individuals posing as Point32Health recruiters have placed job advertisements and reached out to potential candidates. These advertisements or individuals may ask the applicant to make a payment. Point32Health would never ask an applicant to make a payment related to a job application or job offer, or to pay for workplace equipment. If you have any concerns about the legitimacy of a job posting or recruiting contact, you may contact TA_operations@point32health.org